1002

Abstract

Case Reports: Gastric decontamination in ingestion has been deemphasized in the recent past predicated on extensive evidence-based medicine review and guidelines. We describe a case of life-threatening ingestion complicated by a charcoal-medication gastric bezoar that was removed by EGD at 18 hours (h) post ingestion with subsequent abatement of symptoms. A 16-year-old female was found unresponsive with labored breathing and generalized seizures after an ingestion of an unknown quantity of bupropion and aripiprazole tablets. She was intubated by pre-hospital responders and at the outside hospital received 3L of crystalloid and dopamine and norepinephrine drips to maintain a MAP >60 torr. Seizures were controlled with lorazepam and phenytoin. Activated charcoal was delivered via NG tube. Benztropine was given for suspected extrapyramidal movements and dantrolene for increased temperature (T). At PICU admission, she was unresponsive with poor perfusion, BP 82/36, HR 153, T 38.1, SaO2 94% on FiO2 1.0 and PEEP 8 cm H2O. Exam was significant for 1+ pulses, 5mm minimally reactive pupils, no eye opening, weak corneal reflex, hyperreflexic lower extremity DTRs and marginal withdrawal to stimuli. ARDS and hypotension dominated the early course despite additional fluid resuscitation, dopamine, milrinone and norepinephrine. A T 41?C prompted neuromuscular blockade, midazolam and cyproheptadine for presumptive serotonin syndrome. At 18 h, EGD revealed a large intragastric mass of charcoal with intact and fragmented pills. Medication concretions were removed by endoscopy-directed high pressure lavage and additional extrication of 5 intact pills via a retrieval basket. Within 12 h the patient became euthermic with continued cardiopulmonary improvement allowing norepinephrine cessation at 40 h and extubation at 60 h. The patient recovered intact. This case illustrates the need to consider pharmacobezoars in ingestions with refractory toxicity and the potential role for delayed aggressive gut decontamination with EGD. Consideration criteria may also include delayed or recurrent toxicity, absorption characteristics, gastro-intestinal ileus, altered pharmacokinetics and radiologic findings.